48 SCHOOL ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
,
(//► Massachusetts State Building Code, 780 CMR, 7m edition OF SALEM
Revised Jwmary
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Two-FaniA Dwelling
This Section or fficial Us Only
Building Permit Nu er: a e J
Signature: f _ P� /t2
Building ommissioner/Irtsl5ector of Buildin Date
SECTION l:SITE INFORMATION
1.1 q Property ddress: 1/J� 1.2 Assessors Map& Parcel Numbers
n ran C\Y
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 ning Information: 1.4, Prope Dimensions:
Ian
Zoning Distract Proposed Use Lot Area(sq B) Fron
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
3- 1 v ,t
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Food Zone Infor ation: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? MunicipalN On site disposal system ❑
Public] Private❑ Check ifyes1w po y
SECTION 2: PROPERTY OWNERSHIP'
Ile 2. .{pwner'ofLRecord: / I� r /' / / �n
OI L— o 4-1 L r.aa/) pYkP� M 1'k! L 1 7 ,2Gv/1 Lift ) /F
Name Address for Service:
m✓6 AV-L' ! i 7r .7-7 `7 V 6
Signature 'releplione
SECTION 3:DESCRIPTION OF PROPOSED WORK:(check all that apply)
New Construction❑ 1 Existing Building Dt tepairs(s) P I Alteration(s) ❑ I Addition 10
Demolition ❑ Accessory Bldg.❑ Number of Units - Other ❑ Specify:
Brief Description of Proposed Work'': l e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ O I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
to 0 D' 0 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 0'0 0. Gb 2. Other Fees: $
4. Mechanical (FIVAC) $ 10
List:
5. Mechanical (Fire S Total All Fees: $
Su ression
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: $ 30, 0 D0 Cl Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CST 7 1 S
1—' r I'( fo L License Number Expiration Date
NJa3e ram-Ilu err List CSL Type(see below) 1 '
AddressT' Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted I&2 Family Dwelling
Signal M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
Q��.•�`! ��O�L SF Residential Solid Fuel Burning Appliance Installation
I V / D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) /3531 1
HIC Co pany Name or HIC Re strant Name Registration Number
. 93 P Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........W No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT 05 CONTRACTOR APPLIES FOR BUILDING PERMIT p /
1, — / (0 es wne o the su(bject property hereby
authori a r k— 5e� to act on my behalf, in all matters
relative t ork authorized by this building permit application.
A kA�
r u- r—l a
Si a of caner ate
n/ ,. rI SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, at Cr ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Err 5o)C
Print N
��-/tv
Signature orOwner or Authorized Agent Dale
Si ned under the pains and penalties ofperjury)
NOTES.
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.116 and 110,115,respectively.
2. When substantial work i pla ed,p rovide t e information below:
Total floors area(Sq. Ft., � (including garage,finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count I
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system 0 Number of decks/porches ��—
Type of cooling system Enclosed r2__6pen
3. "Total Project Square Footage"may be substituted for"Total Project Cost'
CITY OF S.�I.E.`Is AxSS.,CHL""SETTS
BUILDING DEPARTMENT
I'_0 w.►SHLNGTON STREET. Ya FLOOR
T L (978) 74.9595
R u(978) 7449846
KImIlEP FY DUSCOL
HAYOII THosw ST.PtERRs
DIRECTOR OF PL tlLIC PROPERTY/lIV ILDLNG CONLNDSSION ER
Workers' Compensation Insurance Affldsvit: Builders/ContractorslElectrlclansiPlumbers t
.k s Ilcant Information �f / PIPrint
�lalne ltlusinasa OrgantrationlmLvtduall: �' f S T I yr PVbVLS*Jz
Address:
!j'S R, x v f
City/State/Zip: bou%yRrs abets,- 0 VU-3 phone#- 11-ire-76G—17S6
,%re you as employer!Cheek the appropriate beer: Type of project(requke*
1.Q I am a employer with •• Q 1 errs a general eonaactor and 1
employees(fell and/or part-time).• have hired the subcwmacw a b' Q Now construction
2.9 1 an a sole proprietor Or partner- listed on the attached#heal.: 7• 91tem odelins
.,hip and have no employee Then sub-contractors have V. Q Demolition
working for me in any capacity. workers'comp.inauranoe. 9. IV Building addition
INo workers'comp. insurance S. Q We are a corporation and its
mquircd.)
walkers have exercised their 10Q Electrical repairs or additions
).Q I am a homeowner doing all work right of exemption per MOL I I.0 Plumbing repairs or additions
myself.INo workers'comp. C. 132,41(4),and we have no 12.0 Roof repairs
insurance required.)t employees.LNG workers' IS.❑
comp insurance required.)
other-
.Any xppucam the ahoc4 aloe et mars at"0m caw the swdioa allow Showiy thek works'oanMeadn policy ingxwo lo►
'I hwwuwsc who subnil dais&MdWW indledne they as loin/am wait aad thoo him/wide emraaan mama aMnk s tw a111aYaiil inditarip rak
1'.mimlow AM cheek this!era mWl anaehed as addi,nd deers showing dos antes sane wa►smiatim and thsk wMIMMI 'rang.policy inl'omaioa
I an as employer that b p ovid/np workers'cowprasndon/nsanace for my rarpleyera Below is Ike pel/cy aad/s1 r/sr
inforwas"
Insurance Company Name:
Policy N or Self-ins. Lie.N Expiration Data•
Job Site Address: City/State/Zip: J
attack a copy of the workers'compensation policy declaration pap(showing Ike policy member and expiration dnto).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties ore
fine up to S 1.300.00 and/or one-year imprisonment,am well as civil penalties in the form of it STOP WORK ORDER and a Rne
Of up to S230.00 i Jay againsl the violator. Ise advi*:d that a copy of this statement maybe forwarded to the otylce of
Inv:ali Sit iuna ol'the n1A far insurance coverage veitication.
/do hereby coo*Undef the pains and yenuh/re o/Fer/ury that Ike informottem provid[rdd ubove is true and corral
O/)7ria!oat togs Do n a trri/I in this carry a be.urnpli/d by slay or town,t//&•rat[
I
City orruwn: PirmidUcenseN__. _
i
1%suing Authunty (circle une):
I. Iloard of Ilvollh I. Ruilding Department I C'Ilyffown Clerk J. Electrical litspccior 5. Plumbing Impeetor
6. other
U"ItaeI Pcnon: _ ._ Phone N:
T
S CITY OF SALEM
PUBLIC PROPRERTY
Qj DEPARTMENT
.1'dR Nl fl '•N Iv 1'•I1
M
I rl:971.745.9395 01:.%X:978•740"1916
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.3
Debris, and the provisions of MGL c 40,S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
i 11. S 150A.
The debris will be transported by:
1 name of hauler)
The debris will be disposed Orin
.� LI.
(name of facilityj
no✓wb�,�yS�-
(addre+x of facility)
Signature of Itarmit applicant
date
i
w
13 4 SFL
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11 OFP 8 )
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SFL 1
10 FFL
BMT
16
28 4
10 FFL
14 -BMT
(40)
2 6 SFL
SFL.
10 FFL 36
OFP BMT
0 (832) 28
22
12
8